Essential Nutrient Interactions with Medications

Introduction

At all life transitions, it is wise to take nutritional supplements. During childhood, especially for children who do not eat a balanced diet or who consume sugar foods, which deplete body nutrients, an extra daily multivitamin/mineral is a good idea. For elderly people, whose digestive systems are not always working optimally and some of whose nutrient needs may be increased, especially for such minerals as calcium, magnesium, and potassium, extra supplementation may help with continued vitality and health.

Due to enormous leap ahead of medical science, success of main-stream pharmaceuticals (and we hope, equally nutraceuticals) we do live longer. Provided we dutifully take prescribed medication. However, supplementation is regarded as a bio-hack en mass. Which means people are buying and using supplements increasingly, without really giving a second thought. In 2017, the North American nutraceuticals market was approximately the same size as beer market ($36.1 billion vs $37 billion), but is expected to be worth $126 billion by 2022 exceeding beer sales almost 4 times!

Here comes the risk! Nutraceuticals are not always formulated keeping in mind a slew of medical conditions the potential user can suffer and medications he takes to deal with them. In this article, we hope to give a hand to our colleagues and shed some light on possible supplement-medication interactions as essential nutrients can interact with certain medications, and some medications can have an adverse effect on essential nutrient levels.

Wellness professionals have to ensure that individuals taking medications on a regular basis discuss affected vitamin/nutrient status with their healthcare providers.

Assessment of nutritional balance brings cost-effective immediate answers when your client:

  • Feels stressed, tired, depressed
  • Takes prescription meds but cannot alleviate symptoms
  • Wants to achieve optimal wellness, prevent chronic disease, and manage aging process

Nutri-IQis a unique tool that helps Wellness Professionals to easy and conveniently identify clients’ nutritional gaps as possible causes for clients’ complaints.

Interaction of essential nutrients taken with certain medications is discussed below.

Vitamin A

MedicationsNature of interaction
Abciximab, acenocoumarol, ancrod, anisindione,
antithrombin III human, argatroban, bivalirudin,
clopidogrel, danaparoid, defibrotide,
dermatan sulfate, desirudin, dicumarol,
eptifibatide, fondaparinux, heparin,
lamifiban, pentosan polysulfate sodium, phenindione, phenprocoumon, sibrafiban, tirofiban, warfarin, xemilofiban 
Increased risk of bleeding 
Acitretin, carob, etretinate, isotretinoin, tretinoin, retinoidsIncreased risk of vitamin A toxicity 
Bexarotene Increased risk of retinoid toxicity 
Colestipol, orlistatDecreased vitamin A effectiveness 
Minocycline Increased risk of pseudotumor cerebri (benign intracranial hypertension) 

Vitamin B1 (Thiamin)

Medications Type of interaction 
FurosemideDecrease in thiamin concentrations.
Chemotherapy with FluorouracilRisk of beriberi or Wernicke’s encephalopathy
Nicotine Flushing and dizziness 

Vitamin B3 (Niacin)

MedicationsNature of interaction
Atorvastatin, cerivastatin, fluvastatin, pravastatin, rosuvastatin,
simvastatin 
Increased risk of myopathy or rhabdomyolysis 
Cholestyramine, colestipol Decreased niacin absorption 
Nicotine Flushing and dizziness 
Isoniazid, pyrazinamide Decreased niacin status, pellagra
Antidiabetes medications: biguanide (metformin),  sulfonylureas
(glyburide, glimepiride), meglitinides (nateglinide, repaglinide),
DPP-4 inhibitors (saxagliptin, sitagliptin),
GLP-1 agonists (exenatide, liraglutide, albiglutide),
SGLT-2 inhibitors (canagliflozin, dapagliflozin, empagliflozin),
alpha-glucosidase inhibitors (acarbose),
thiazolidinediones (pioglitazone),
amylin analogs (pramlintide)
Decreased effectiveness, increased blood
glucose levels

Pyridoxine (Vitamin B6)

MedicationsNature of interaction
Altretamine Adversely affects the response duration of altretamine 
Amiodarone Enhances amiodarone-induced photosensitivity reactions 
Contraceptives (combination), cycloserine (Seromycin®),
hydralazine, isoniazid, penicillamine 
May increase vitamin B6 requirements 
Fosphenytoin, phenytoin Reduced phenytoin concentrations 
Levodopa Decreased drug effectiveness 
Valproic acid (Depakene®, Stavzor®), carbamazepine
(Carbatrol®, Epitol®, Tegretol®, and others), and phenytoin
(Dilantin®); Theophylline (Aquaphyllin®,
Elixophyllin®, Theolair®, Truxophyllin®)
Adversely affects B6 status / plasma PLP concentrations
Levetiracetam (Keppra®) Reduce side effects of medication

Folic Acid (Folate, Vitamin B9)

MedicationsNature of interaction
Colestipol, oristatDecreased bioavailability of 
vitamin and mineral 
preparations possible 
Fosphenytoin, phenytoin Increased seizure frequency and 
decreased phenytoin concentrations 
Methotrexate (Rheumatrex®, Trexall®)Folate could interfere with anticancer effects
Methotrexate (Rheumatrex®, Trexall®) – 
low dose
Folate could reduce gastrointestinal 
side effects
Pancreatin, sulfasalazine Decreased absorption of folate 
Phenytoin (Dilantin®), carbamazepine (Carbatrol®, 
Tegretol®, Equetro®, Epitol®), valproate (Depacon®)
Drugs reduce serum folate levels.
Folate supplements might reduce serum levels 
of these medications
Pyrimethamine Pharmacodynamic antagonism 
of the antiparasitic effect 
RetinoidsIncreased bioavailability of 
vitamin A and other fat-soluble vitamins
Sulfasalazine (Azulfidine®) Inhibits the intestinal absorption of folate
Triamterene Decreased utilization of dietary folate 

Vitamin B12 (Cobalamin)

MedicationsNature of interaction
Aminosalicylic acid, cimetidine (Tagamet®), famotidine (Pepcid®), and ranitidine (Zantac®).Reduced vitamin B12 absorption 
Vitamin CReduced amounts of cyanocobalamin
available for serum and body stores 
Chloramphenicol Decreased hematologic response to cyanocobalamin 
Colestipol May decrease the bioavailability of vitamin and mineral preparations 
Contraceptives (combination) Decrease in serum vitamin B12 concentrations 
Proton pump inhibitors, such as omeprazole (Prilosec®) and lansoprazole (Prevacid®)Decrease absorption of B12 by slowing the release of gastric acid into the stomach

Biotin

MedicationsNature of interaction
Carbamazepine (Tegretol®, Carbatrol®, Epitol®, Equetro®),
primidone (Mysoline®), phenytoin (Dilantin®, Phenytek®),
phenobarbital (Luminal®, Solfoton®);
as well as combinations of these medications
Increase biotin catabolism, reduce biotin status;
inhibit intestinal biotin absorption

Vitamin C

MedicationsNature of interaction
Aluminum carbonate (basic), aluminum hydroxide, aluminum phosphate,
dihydroxyaluminum aminoacetate, dihydroxyaluminum sodium carbonate, magaldrate 
Aluminum toxicity (personality changes, seizures, coma) 
Amygdalin Increased metabolism of amygdalin, leading to increased cyanide concentrations 
Chemotherapeutic agents: cyclophosphamide, chlorambucil,
carmustine, busulfan, thiotepa, and doxorubicin
Vitamin C might protect tumour cells from the action of radiation therapy and chemotherapeutic agents
Cyanocobalamin Reduced amounts of cyanocobalamin available for serum and body stores 
Indinavir Decreased plasma indinavir concentrations 
Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors)May attenuate the increase in high-density lipoprotein levels
resulting from combination niacin–simvastatin (Zocor®) therapy

Vitamin D

MedicationsNature of interaction
Corticosteroid medications (prednisone)Impair vitamin D metabolism
Orlistat (Xenical®, alliTM),
cholestyramine (Questran®, LoCholest®, and Prevalite®)
Can reduce the absorption of vitamin D
Phenobarbital, phenytoin (Dilantin®)Increase hepatic inactivation of vitamin D and reduce calcium absorption

Vitamin E

MedicationsNature of interaction
Anisindione, phenprocoumon Enhanced response to anticoagulants 
Cholestyramine Malabsorption of fat-soluble vitamins, decrease in fat-soluble vitamin absorption 
Colestipol, orlistat Decreased vitamin E effectiveness 
Dicumarol, warfarin (Coumadin®)Increased risk of bleeding 
Simvastatin (Zocor®) with niacin and other antioxidantsRise in high-density lipoprotein (HDL) cholesterol
Chemotherapy drugsAntioxidants might protect tumour cells from the
action of radiation therapy and chemotherapeutic agents

Vitamin K

MedicationsNature of interaction
AntibioticsDestroy vitamin K-producing bacteria in the gut, potentially decreasing vitamin K status
Cefoperazone (Cefobid®)More pronounced effect of inhibiting the action of vitamin K
Cholestyramine (Questran®), colestipol (Colestid®)Reduce absorption of vitamin K and other fat-soluble vitamins
Pau d’arco Reduced vitamin K effectiveness 
OrlistatCan reduce absorption of fat-soluble vitamins, such as vitamin K
Warfarin (Coumadin®) and similar anticoagulantsDecreased anticoagulant effectiveness 

Calcium

MedicationsNature of interaction
Alendronate, etidronate, levothyroxine, risedronate, tiludronate,
bisphosphonates, fluoroquinolone and tetracycline
classes of antibiotics, levothyroxine, phenytoin, tiludronate disodium
Reduced drug absorption 
Aluminum- and magnesium-containing antacidsIncrease urinary calcium excretion
Amprenavir, aspirin, atenolol, bisacodyl, bismuth subcitrate, cefpodoxime,
proxetil, chlortetracycline, ciprofloxacin, demeclocycline, doxycycline, enoxacin,
gemifloxacin, grepafloxacin, hyoscyamine, ibandronate, iron,
itraconazole, ketoconazole, levofloxacin, lomefloxacin, methacycline,
minocycline, norfloxacin, ofloxacin, oxytetracycline, pefloxacin,
rolitetracycline, sparfloxacin, sucralfate, temafloxacin, tetracycline,
ticlopidine, trovafloxacin mesylate, zalcitabine 
Reduced drug efficacy 
Atazanavir Reduced plasma concentration of drug 
Bemetizide, bendroflumethiazide, benzthiazide, buthiazide,
chlorothiazide, chlorthalidone, clopamide, cyclopenthiazide,
cyclothiazide, hydrochlorothiazide, hydroflumethiazide, indapamide,
methyclothiazide, metolazone, polystyrene sulfonate,
polythiazide, quinethazone, trichlormethiazide, xipamide 
Milk-alkali syndrome (hypercalcemia, metabolic alkalosis, renal failure) 
Digitoxin, digoxin Cardiotoxicity: arrhythmia and cardiovascular collapse 
Glucocorticoids, such as prednisoneCan cause calcium depletion
Guar gum Delayed calcium absorption 
Mineral oil and stimulant laxatives Decreased calcium absorption
Potassium phosphate, potassium phosphate (dibasic),
potassium phosphate (monobasic), sodium phosphate,
sodium phosphate (dibasic), sodium phosphate (monobasic) 
Decreased phosphate absorption 
Thiazide-type diureticsIncreased risks of hypercalcemia and hypercalciuria
with calcium carbonate and vitamin D supplements
Verapamil Reversal of hypotensive effects 

Chromium

MedicationsNature of interaction
Antacids, corticosteroids, H2 blockers (such as cimetidine,
famotidine, nizatidine, and rantidine), proton-pump inhibitors
(such as omeprazole, lansoprazole, rabeprazole, pantoprazole,
and esomeprazole)
Alter stomach acidity and may impair chromium absorption or enhance excretion
Beta-blockers (such as atenolol or propanolol), corticosteroids,
insulin, nicotinic acid, Nonsteroidal anti-inflammatory
drugs (NSAIDS), prostaglandin inhibitors (such as ibuprofen, indomethacin, naproxen, piroxicam, and aspirin)
May have their effects enhanced if taken together with chromium or they may increase chromium absorption

Iodine

MedicationsNature of interaction
Angiotensin-converting enzyme (ACE) inhibitors:
benazepril (Lotensin®), lisinopril (Prinivil® and Zestril®), fosinopril (Monopril®),
Taking with potassium iodide can increase the risk of hyperkalemia
Methimazole (Tapazole®)Could cause hypothyroidism if taken high doses of iodine
Potassium-sparing diuretics, such as spironolactone (Aldactone®) and amiloride (Midamor®)Taking with potassium iodide can increase the risk of hyperkalemia

Iron

Medications Nature of interaction
Acetohydroxamic acid, cefdinir, cinoxacin, ciprofloxacin, 
demeclocycline, doxycycline, gatifloxacin, gemifloxacin, 
grepafloxacin, ibandronate, levodopa (Sinemet® , Stalevo®),
levofloxacin, lomefloxacin, methacycline, methyldopa,
minocycline, moxifloxacin, mycophenolate mofetil, n
orfloxacin, ofloxacin, oxytetracycline, 
penicillamine, rolitetracycline, temafloxacin, tetracycline, 
trovafloxacin mesylate 
Decreased drug effectiveness 
Acetohydroxamic acid, aluminum carbonate basic, 
aluminum hydroxide, aluminum phosphate, calcium, 
chloramphenicol, cholestyramine, 
demeclocycline, dihydroxyaluminum aminoacetate, 
dihydroxyaluminum sodium carbonate, doxycycline, 
enoxacin, magaldrate, magnesium carbonate, 
magnesium hydroxide, magnesium oxide, 
magnesium trisilicate, methacycline, minocycline,
oxytetracycline, rolitetracycline, sodium bicarbonate, tetracycline 
Decreased iron effectiveness 
Etidronate, sparfloxacin, trientine, zinc Reduced drug absorption 
Gossypol, soy protein, trientine, vanadium, zinc Reduced iron absorption 
Esomeprazole, lansoprazole, omeprazole, 
pantoprazole, rabeprazole 
Reduced iron bioavailability 
Levothyroxine (Levothroid®, Levoxyl®, Synthroid®,
Tirosint®, Unithroid®)
Hypothyroidism
Levothyroxine (Levothroid®, Levoxyl®, Synthroid®,
Tirosint®, Unithroid®)
Iron supplements (taken simultaneously)
reduce effacity of medication

Magnesium

MedicationsNature of interaction
Allopurinol, amprenavir, aspirin, atazanavir, azithromycin,
bisacodyl, bismuth, subcitrate, captopril, cefdinir,
cefditoren pivoxil, cefpodoxime proxetil, chloroquine,
chlorpromazine, chlortetracycline, cimetidine, cinoxacin,
ciprofloxacin (Cipro®), demeclocycline (Declomycin®),
doxycycline (Vibramycin®), enoxacin,
fexofenadine, gabapentin, gatifloxacin, gemifloxacin,
grepafloxacin, hyoscyamine, ibandronate, iron,
itraconazole, levofloxacin (Levaquin®), levothyroxine,
lomefloxacin, minocycline, misoprostol, moxifloxacin,
mycophenolate mofetil, nalidixic acid,
norfloxacin, ofloxacin, oxytetracycline,
pefloxacin, penicillamine, rolitetracycline,
rosuvastatin, rufloxacin, sotalol, sparfloxacin,
sucralfate, temafloxacin, tetracycline, ticlopidine,
tipranavir, trovafloxacin mesylate, zalcitabine 
Decreased drug effectiveness 
Alendronate (Fosamax®), atevirdine, etidronate,
mycophenolate sodium, mycophenolic acid,
potassium phosphate, risedronate,sodium phosphate, tiludronate 
Decreased drug absorption 
Delavirdine, lansoprazole Decreased drug bioavailability 
Calcitriol, doxercalciferol Hypermagnesemia 
Atazanavir, clofazimine, digoxin Decreased plasma drug concentration 
Amikacin, dibekacin, gentamicin, kanamycin, netilmicin,
streptomycin, tobramycin 
Neuromuscular weakness 
Cisatracurium, rapacuronium, succinylcholine, vecuronium Enhanced neuromuscular blockade 
Dicumarol Increased risk of bleeding 
Didanosine, mefenamic acid, quinidine, rocuronium Increased risk of adverse drug effects 
Esomeprazole magnesium (Nexium®), lansoprazole (Prevacid®)
taken more than a year
Can cause hypomagnesemia
Felodipine, isradipine Hypotension 
Furosemide (Lasix®), bumetanide (Bumex®), thiazide,
hydrochlorothiazide (Aquazide H®), ethacrynic acid (Edecrin®)
Magnesium depletion
Glipizide, glyburide, nicardipine, nifedipine Hypoglycemia 
Labetalol Bradycardia and decreased cardiac output 
Polystyrene sulfonate Increased risk of metabolic alkalosis 
Levomethadyl Increased risk of QT prolongation 
Tacrolimus Increased drug exposure 

Phosphorus

MedicationsNature of interaction
AlcoholDeplete phosphorus from the body
Antacides (Mylanta, Amphojel, Maalox, Riopan, and Alternagel)Low phosphate status
Anticonvulsants (phenobarbital, carbamazepine, Tegretol)May lower phosphorus levels and increase levels of alkaline phosphatase, an enzyme that helps remove phosphate from the body
Benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec),
fosinopril (Monopril), lisinopril (Zestril, Prinivil), quinapril (Accupril), or ramipril (Altace); cyclosporine, digoxin, Lanoxin, heparins, ibuprofen, Motrin; salt-substitutes
May decrease phosphorus levels
Cholestyramine (Questran), colestipol (Colestid)Decrease the oral absorption of phosphates from the diet or from supplements
Corticosteroids including prednisone (Deltasone) or
methylprednisolone (Medrol)
May increase urinary phosphorus levels
Diuretics: hydrochlorothiazide (Hydrodiuril) or
urosemide (Lasix)
Increase the elimination of phosphorus from the body in the urine causing symptoms of phosphorus deficiency
High doses of insulinDecrease blood levels of phosphorus in people with diabetic ketoacidosis
Potassium supplements or potassium-sparing diuretics 
including spironolactone (Aldactone), triamterene (Dyrenium)
May cause high blood levels of potassium (hyperkalemia)

Potassium

MedicationsNature of interaction
ACE inhibitors (benazepril or Lotensin®), ARBs (losartan or Cozaar®);
potassium-sparing diuretics (amiloride or Midamor®;
spironolactone or Aldactone®)
Hyperkalemia due to reduced urinary potassium excretion
Loop diuretics (furosemide or Lasix®, bumetanide or Bumex®),
thiazide diuretics (chlorothiazide or Diuril®,
metolazone or Zaroxolyn®)
Hypokealemia due to increased urinary potassium excretion

Selenium

MedicationsNature of interaction
ChemotherapySelenium could alleviate side effects of chemotherapy 
Cisplatin (inorganic platinum chemotherapy agent)Can reduce selenium levels in hair and serum

Sodium

MedicationsNature of interaction
LithiumUsing with sodium chloride may decrease effects of the medication
 Tolvaptan May cause sodium levels to increase too rapidly

Zinc

MedicationsNature of interaction
Cinoxacin, ciprofloxacin, enoxacin, gatifloxacin,
grepafloxacin, levofloxacin, moxifloxacin,
norfloxacin, ofloxacin, tetracycline 
Decreased drug effectiveness and
zinc absorption
Thiazide diuretics (chlorthalidone (Hygroton®),
hydrochlorothiazide (Esidrix® and HydroDIURIL®)
Deplete zinc tissue levels
Gemifloxacin, sparfloxacin Decreased drug absorption 
Penicillamine Decreased zinc absorption 
Copper Decreased zinc or copper absorption 
Iron Decreased zinc or iron absorption 

Essential Fatty Acids

MedicationsNature of interaction
Atorvastatin (Liptor), lovastatin (Mevacor), simvastatin (Zocor) Medication works more effectively 
Cancer therapy (doxorubicin, cisplatin, carboplatin, idarubicin, mitoxantrone, tamoxifen, vincristine, and vinblastine)GLA may increase the effects of anti-cancer treatments
Ceftazidime Gamma linolenic acid (GLA) may increase the
effectiveness of medication
CyclosporineTaking omega-3 and omega-6 fatty acids during
cyclosporine (Sandimmune) therapy may reduce
toxic side effects, such as high blood pressure and kidney damage, associated with this medication in transplant patients
Etretinate and topical steroids Addition of omega-3 fatty acids (specifically EPA) to the drug therapy may improve symptoms of psoriasis.
Glipizide (Glucotrol and Glucotrol XL), glyburide (Micronase or Diabeta), glucophage (Metformin), or insulinMay increase fasting blood sugar levels 
Hlorpromazine (Thorazine), fluphenazine (Stelazine), perphenazine (Trilafon), promethazine (Compazine), thioridazine (Mellaril)  Omega-6 from evening primrose oil (EPO) may increase the risk of seizure 
NSAIDs including ibuprofen (Motrin or Advil) and naproxen (Alleve or Naprosyn).  Reduced the risk of side effects (ulcers)
 Warfarin (Coumadin®) and similar anticoagulantsMight have antiplatelet effects at high doses, might prolong clotting times.

References

  1. Elizabeth A Yetley, Multivitamin and multimineral dietary supplements: definitions, characterization, bioavailability, and drug interactions, The American Journal of Clinical Nutrition, Volume 85, Issue 1, January 2007, Pages 269S–276S, https://doi.org/10.1093/ajcn/85.1.269S
  2. Elson Haas. “Staying Healthy with Nutrition”
  3. Merck Manual for the Professional: https://www.merckmanuals.com/en-ca/professional
  4. Reuters research: https://www.reuters.com/brandfeatures/venture-capital/article?id=104499
  5. Mordor Intelligence: https://www.mordorintelligence.com/industry-reports/north-america-nutraceutical-market
  6. PennState Health – Milton S. Hershey medical Center: http://pennstatehershey.adam.com/content.aspx?productId=107&pid=33&gid=000974
  7. US Department of Health and Human Services, Office of Dietary Supplements: https://ods.od.nih.gov

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